News highlights

Long-acting inhaled therapies, supplemental oxygen and pulmonary rehabilitation are beneficial for patients with chronic obstructive pulmonary disease (COPD), said new practice guidelines released today by ACP.

The guideline, published in the Nov. 6 issue of Annals of Internal Medicine, is based on a systematic evidence review of published studies by Timothy J. Wilt, FACP, and the Agency for Healthcare Research and Quality-sponsored Minnesota Evidence-based Practice Center evidence report.

The guideline offers six recommendations, including:

In patients with respiratory symptoms, particularly shortness of breath, spirometry should be performed to diagnose airflow obstruction. Spirometry should not be used to screen for airflow obstruction in asymptomatic individuals.

Treatment of stable COPD should be reserved for patients who have respiratory symptoms and forced expiratory volume in one second (FEV1) less than 60% predicted, as documented by spirometry.

For symptomatic patients with COPD and FEV1 less than 60% predicted, clinicians should prescribe long-acting inhaled beta-agonists, long-acting inhaled anticholinergics or inhaled corticosteroids.

Clinicians should prescribe oxygen therapy in patients with COPD who have insufficient levels of oxygen in the circulating blood while resting.

COPD affects more than 5% of the adult population in the U.S. and is the fourth-leading cause of death and twelfth-leading cause of illness. The symptoms of COPD range from chronic cough and wheezing to more severe symptoms such as shortness of breath and significant activity limitation.

Younger depressed veterans are more likely to commit suicide than depressed older veterans, and post-traumatic stress disorder (PTSD) actually mitigates suicide risk, an Oct. 30 study in the American Journal of Public Health found.

The retrospective cohort study looked at the records of 807,694 patients diagnosed with depression in Veterans Affairs facilities between April 1999 and October 2004. Patients with bipolar I, schizophrenia or schizoaffective diagnoses were excluded from the study. Researchers examined patient age, race, gender, substance abuse and post-traumatic stress disorder comorbidity, among other factors.

The suicide rate in the depressed VA population was 0.21%, similar to that of men receiving depression treatment in a large managed-care setting, the authors said. Unlike in the general population, younger depressed veterans (ages 18 to 44) were at greater risk of suicide than depressed veterans ages 45 to 64 (94.98 per 100,000 person-years vs. 77.93), though the risk climbed for those older than age 65 years (90.06 per 100,000 person-years). Depressed veterans with PTSD had lower suicide risk than those without PTSD (68.6 vs. 90.66 per 100,000 person-years), though this effect was weaker with younger veterans. A possible reason for the PTSD finding is that these patients receive more mental health treatment due to specific VA initiatives targeting PTSD, the authors said.

Substance abuse conferred additional risk, as did prior VA hospitalization for a psychiatric diagnosis. Males had higher suicide risk than females, and whites had a higher risk than blacks, Hispanics or other races. In general, the study’s findings can help physicians determine which veterans they need to monitor more closely for symptoms of potential suicidal behavior, the authors said.

PHILADELPHIA--The cost of practicing medicine continues to increase for many physician specialties, according to new studies by the Medical Group Management Association (MGMA). The research was released during the MGMA’s annual meeting held here Oct. 28-31.

According to the group’s annual cost survey, multispecialty practices faced some of the most negative trends in cost/revenue ratios. These practices’ cost per full-time-equivalent physician increased 7.4% while revenue rose only 1.8%. Family practice, cardiology and general surgery also saw cost increases paired with very small gains or even losses in revenue. Pediatrics and orthopedic surgery were among the specialties with positive revenue-to-cost ratios.

The rise in operating costs cannot be attributed to malpractice rates, however. The study found that liability insurance costs had actually decreased for several specialties between 2005 and 2006, reversing a trend of increasing rates that had held for the past several years. Internal medicine saw one of the biggest drops, with liability premiums dropping 9.6%, the MGMA research found. The MGMA cost survey report is based on data submitted by more than 38,460 providers.

Another survey of MGMA members found that practices that participate in Medicare’s Physician Quality Reporting Initiative (PQRI) incur additional administrative work and costs. About 35% of responding practices had to create an addendum to their “superbill” paperwork to report the quality codes, and approximately 22% of the practices required additional staff support to track the measures. Only 13% of participants rated the PQRI’s helpfulness to patients as good or excellent. The survey indicates the perils of encouraging medical practices to report on quality measures without first providing incentives to build the infrastructure needed to collect the data (i.e., electronic medical records), said MGMA president and CEO William F. Jessee, MD.

Hospital medicine

The American Academy of Neurology has issued new guidelines on emergency department imaging in patients who present with seizure.

According to the guidelines, which were developed after a review of the literature and appear in the Oct. 30 issue of Neurology, emergency computed tomography (CT) may be considered in adults and children with first seizure, children younger than six months and patients with AIDS. The guidelines also recommended consideration of immediate CT in patients who present with seizure in the ED and have abnormal findings on neurologic examination, a predisposing history or focal seizure onset. Evidence indicates that CT will change treatment in up to 17% of adults and 8% of children presenting with a first seizure in the ED, the guideline authors found.

None of the recommendations were level A, the strongest category, because the studies reviewed had methodologic limitations such as lack of blinding, the guideline authors wrote. However, they noted, emergency treatment of seizures is difficult to study in blinded trials. The authors recommended that future research should examine the use of magnetic resonance imaging, which may be more sensitive than CT for determining seizures' underlying causes.

Clinical news

Incidental brain findings on magnetic resonance imaging (MRI) are common in the general population, according to a new study.

MRIs of the brain are being performed more frequently in both research settings and in clinical medicine, and MRI equipment itself is becoming more sensitive. As a result, more asymptomatic people may be diagnosed as having incidental brain findings. Researchers in the Netherlands examined high-resolution brain MRIs performed on 2,000 participants in the Rotterdam Study to determine the prevalence of these findings in the general population.

Incidental MRI findings that could be clinically relevant were defined as those requiring immediate or urgent referral. All MRIs were read by a resident in radiology or neurology, and two neuroradiologists further reviewed any MRIs on which abnormalities were reported and arrived at a consensus. Any person whose findings required more tests or treatment was referred to a specialist as needed. The study appears in the Nov. 1 New England Journal of Medicine.

Of the 2,000 persons who underwent brain MRI, 7.2% had asymptomatic brain infarcts, 1.8% had cerebral aneurysms and 1.6% had benign primary tumors, mostly meningiomas. The prevalence of asymptomatic brain infarcts and meningiomas and the median volume of white-matter lesions increased with age, while aneurysm prevalence did not. Only two persons with incidental brain findings, one with vestibular schwannoma and one with right-sided intravestibular lipoma, reported having symptoms. Two patients had findings that required surgery (subdural hematoma and a 12-mm aneurysm of the medial cerebral artery).

The authors concluded that incidental brain findings on MRI are common, although they acknowledged that their results may not be generalizable because of the relative homogeneity of the study population. They recommended that researchers designing trials involving brain imaging should take the likelihood of such findings into account, and noted that further information on course and prognosis is necessary for appropriate clinical management.

Several new studies of coronary medications were released at the American Heart Association Scientific Sessions held in Orlando, Fla.

The new research includes:

A report on a trial showing that rosuvastatin did not reduce death from cardiovascular causes, nonfatal myocardial infarction or nonfatal stroke compared to placebo in older patients with systolic heart failure. The medication group did have a lower number of cardiovascular hospitalizations but there was no significant difference in the number of deaths. The trial involved 5,011 patients age 60 or over and will be published in the Nov. 29 print issue of the New England Journal of Medicine.

A report on the halted trial of torcetrapib, a cholesteryl ester transfer protein (CETP) inhibitor that researchers hoped would improve plasma lipoprotein levels and reduce cardiovascular events. Instead, the trial, which randomized 15,000 patients to torcetrapib plus atorvastatin or atorvastatin alone, found that the new drug resulted in an increased risk of mortality and morbidity. Patients in the drug group had increases in blood pressure, serum sodium, bicarbonate and aldosterone, and decreases in serum potassium. Study authors could not determine whether the mortality difference was due to the off-target effects of torcetrapib or related to CETP inhibition. The trial will appear in the Nov. 22 print issue of the New England Journal of Medicine.

A comparison of prasugrel, a new thienopyridine, and clopidogrel in patients with acute coronary syndromes who were scheduled to receive percutaneous coronary intervention. The trial of 13,000 patients found that prasugrel therapy was associated with significantly reduced rates of ischemic events, including stent thrombosis, but had an increased risk of major bleeding, including fatal bleeding. Overall, the groups did not differ significantly for mortality and the study authors concluded that clinicians will need to weigh the benefits and risks of intensive inhibition of platelet aggregation. The study will appear in the Nov. 15 print edition of the New England Journal of Medicine.

The following articles will appear in the Nov. 6, 2007, issue of Annals of Internal Medicine. The full text is available to College members and subscribers online.

Nutrient reduces need for steroids for ulcerative colitis. In a new, 12-week study of 60 adults with steroid-resistant ulcerative colitis, 80% of patients given a slow-release version of phosphatidylcholine (a nutrient or essential fatty acid) were able to stop steroid therapy and improved clinically. Only 10% of those who received a placebo were able to quit steroids and improved clinically.

Antipsychotic drug reduces persistent depression. The atypical antipsychotic drug risperidone, when added to standard antidepressants, improved symptoms of long-term depression more often than placebo, according to a new six-week study. Researchers randomly assigned 274 adults with major depressive disorder who were not responding to standard antidepressant therapy to a group that received risperidone or to a group that received a placebo. Both groups continued to take their other antidepressant medications.

Study finds ACE inhibitors and ARBs both control blood pressure and reduce proteinuria A systematic review of randomized trials comparing angiotensin-converting enzyme (ACE) inhibitors and angiotensin II receptor blockers (ARBs) found that they had similar effects on blood pressure control and equivalent effects on death and cardiovascular events, other major adverse events and quality of life. A separate meta-analysis of data on the effectiveness of ACE inhibitors and ARBs on proteinuria found that both reduce excess urinary protein excretion. The combination of the two is more effective than either drug alone. These articles were released early on the Annals Web site and will appear in the Jan. 1, 2008, print edition.

FDA news

The FDA this week announced that Bayer Pharmaceuticals Corp. agreed to its request to temporarily suspend marketing of the antifibrinolytic drug, aprotinin injection (brand name Trasylol) pending review of study data suggesting an increased risk for death.

Preliminary results from a study performed at the Ottawa Health Institute in Canada suggested an increased risk for death compared to two other antifibrinolytic drugs used on patients undergoing heart surgery, said a Nov. 5 FDA news release. Preliminary data from the study, which was halted early, also suggested that fewer patients receiving aprotinin injection experienced serious bleeding events.

Because of the lack of treatment options for patients at risk for excessive bleeding during cardiac surgery, FDA officials are working with Bayer to phase out aprotinin injection without causing shortages of other drugs in the same class, said the news release. The FDA statement noted that there may be cases where the benefits of using aprotinin injection outweigh the risks and that officials are exploring ways for individual physicians to have continued, limited access to the drug.

On Oct. 26, the FDA announced an ongoing safety review of aprotinin injection in response to the Canadian study's termination. Last year, a strengthened safety warning was added to the drug's label and approved usage was limited to patients at increased risk for blood loss and blood transfusion during coronary bypass graft surgery.

Business of medicine

The CMS' final physician payment rule for 2008 includes $58.9 billion in payments and incentives and extends the Physician Quality Reporting Initiative (PQRI) into next year, among other provisions.

Under the Medicare Physician Fee Schedule final rule, published in the Nov. 1 Federal Register, the PQRI would be extended with $1.35 billion in incentives provided by the Physician Assistance and Quality Initiative Fund, said a Nov. 1 CMS news release. Quality measures used in the PQRI have been endorsed by the National Quality Forum and focus on a provider's use of electronic health records and electronic prescribing.

The PQRI, which began as a voluntary reporting program last July, has allowed participating physicians to earn up to 1.5% of their total allowed charges (subject to a cap) for reporting on specific quality measures. In 2008, physicians not meeting the PQRI measures will be allowed to participate in the program by reporting on their use of health information technology, said the CMS release.

The incentive payments are intended, in part, to counterbalance the scheduled cuts in physician fees mandated by a statutory formula tied to growth in the economy, said the CMS release. In each of the past five years, Congress has intervened to temporarily suspend the required cuts in favor of specific updates.

Some of the other provisions affecting physicians in the final rule include:

The proposal to eliminate the computer-generated fax exemption from e-prescribing was modified to allow a transition period. Until Jan. 1, 2009, the exemption can be used only in instances of temporary/transient transmission failure and communication problems that would preclude the use of the NCPDP SCRIPT standard adopted in the final rule.

CMS will continue payments for pre-admission-related services for intravenous infusion of immunoglobulin (IVIG) for an additional year to cover the cost of locating and obtaining appropriate IVIG products and resources expended to schedule infusions. Health care providers may bill for each related physician office visit when IVIG treatments are administered.

Payments for work involved in providing anesthesia services will be increased by 32% and the value of the work component of certain physician visits to patients’ homes will increase.

Physicians who self-refer patients for imaging or send them to another physician of the same specialty use more imaging than those who refer their patients to a radiologist, according to a new study of diagnostic radiology.

Researchers reviewed more than 18 million insurance claims from 1999-2003 and evaluated the use of diagnostic imaging for six conditions: cardiopulmonary disease, coronary disease, extremity fracture, knee pain, intraabdominal malignancy and stroke. They found that the same-specialty-referring physicians used imaging between 1.12 and 2.29 times as often as physicians who referred to radiologists. After the researchers controlled for patient age and comorbidity, patients who saw the same-specialty referrers were 1.196 to 3.228 times more likely to receive imaging than the patients whose physicians used radiologists.

The study was not able to determine whether the increased use resulted in better care or better patient outcomes, the authors said. They noted that other studies have found consistent results, and that although it is not possible to quantify the effect, the results may indicate that financial incentives play a role in physicians’ use of imaging.

The researchers did mention alternate explanations for their findings. The study found that patients who were referred to same-specialty physicians were more likely to receive imaging on the same day as an office visit, and patients may be more likely to adhere to recommendations when the imaging can be performed immediately. Also, physicians who generally order more imaging may also be more likely to acquire imaging equipment themselves or affiliate with physicians who have the devices. The study was published in the November issue of Radiology.

ACP Publishing news

Readers will notice many changes in the January 2008 edition of ACP's newspaper, which will relaunch as ACP Internist with a new look and expanded content. ACP Internist will feature the same high-caliber reporting that readers have come to expect from ACP Observer, with some notable additions and improvements.

A major goal of the redesign process was to become more engaged with our readers by forging a stronger link between print and Web content and encouraging readers to go online with their comments and feedback. In addition to being a source of news and trends, ACP Internist will be a forum for exchanging ideas and sharing professional frustrations and successes. In that spirit, we welcome some new voices and content to our editorial pages, including:

Mindful Medicine: Jerome Groopman, FACP, author of the bestselling “How Doctors Think,” and his wife, endocrinologist Pamela Hartzband, ACP Member, both faculty members at Harvard, will write about the importance of creative thinking in medicine.

Clinical Ethics: Lachlan Forrow, ACP Member, director of the Ethics Program at Harvard/Beth Israel Deaconess Medical Center, will moderate a column featuring case studies on ethical dilemmas. A panel of experts will provide commentary and readers are encouraged go online to voice their opinions.

ACP Press' "Peripheral Arterial Disease" is the latest addition to its Key Diseases Series, providing clinicians with the most current information on the diagnosis and treatment of peripheral arterial disease (PAD).

Co-edited by Emile R. Mohler, FACP, director of vascular medicine at the University of Pennsylvania Health System and associate professor of medicine at the University of Pennsylvania School of Medicine, "Peripheral Arterial Disease" provides direct and clinically relevant answers to commonly asked questions about this debilitating condition.

The book covers the epidemiology of PAD, evaluation techniques and procedures, testing methods, medical/endovascular/surgical treatment options, management of PAD risk factors, current and future therapies for PAD, and when to refer patients for surgery.

"The number of Americans affected with PAD may quadruple within the next decade as the population continues to age," said co-editor Michael R. Jaff, FACP, assistant professor of medicine at Harvard Medical School and director of the Massachusetts General Hospital Vascular Center. "Yet PAD remains one of the most under-diagnosed conditions in internal medicine. Due to the lack of symptoms associated with PAD, many people suffer from this disease in silence."

ObserverWeekly wants readers to create captions for this cartoon--and help choose the winner.

E-mail all entries to observerstaff@acponline.org by Nov. 12. ACP staff will choose three finalists and post them Nov. 13 for an online vote by readers that week. The winner will appear in the Nov. 20 issue of Weekly.

Pen the winning caption and win "Medicine in Quotations," ACP's comprehensive collection of famous sayings.

College news

The Board of Regents voted at its Oct. 27-28 meeting on several items, including establishment of a College leadership program and an investigation of ways to reduce student debt.

The newly approved College Leadership Enhancement and Development (LEAD) certificate program will help Members and Fellows cultivate leadership skills and expand career opportunities. The program will roll out over the next three years to include educational courses at chapter and annual meetings, as well as freestanding courses; chapter mentoring events and Web-based discussion groups; and participation in events like Leadership Day and College committee activities. It will kick off with a pre-course this spring entitled "Essential Competencies for the Emerging Leader."

Other approved resolutions called for oversight of possible conflicts of interest when medications are prescribed in minute clinics; investigation of private-public partnerships and other non-governmental sources of funding for easing the medical student debt of those entering primary care practice; and advocacy for publicly funded, service-connected medical education scholarship and debt relief.

HHS announced last week that CMS will conduct a five-year demonstration project to provide financial incentives to encourage small and medium-sized medical practices to use certified electronic health records (EHRs).

“CMS’s new electronic health records demonstration project is an encouraging step in the right direction,” said David C. Dale, FACP, president of ACP. “This program marks a significant and positive change to the administration’s previous stance on EHRs. It is appropriately acknowledging that market forces alone will not be enough for physicians to afford new office systems.”

CMS will invite practices of three to five physicians to apply for the five-year program, and will accept a total of 1,200 practices. These practices will get an annual bonus based on their scores on a survey assessing the groups' EHR capabilities. They will have two years to put into place EHR systems that are certified by the Certification Commission for Health IT.

“Increased use of HIT could greatly benefit health care in the U.S. through improved patient care, reduction in medical errors, higher efficiency, and potential long-run cost savings,” concluded Dr. Dale. “However, in order for patients to see any of these benefits we need to ensure that their physicians are able to acquire these important technologies.”

ACP ObserverWeekly is a weekly newsletter produced by the staff of ACP Observer. It is automatically sent to all College members who have an e-mail address on file with ACP.

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Copyright 2007 by the American College of Physicians.

Test yourself

A 54-year-old woman is evaluated for shortness of breath of 3 months' duration and a 4.5-kg (10-lb) weight loss over the preceding 2 months. She has a 35-pack-year smoking history. Following a physical exam and further testing, what is the most appropriate treatment?

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